Äð. Robert L Áàðáèåðè
Ïðîôåññîð Kate Macy Ladd obstetrics, Gynecology è âîñïðîèçâîäñòâåííîé áèîëîãèè, øêîëû harvard ìåäèöèíñêîé; Âîæäü obstetrics è Gynecology, Brigham è ñòàöèîíàðà æåíùèí; Ðóêîâîäèòåëü obstetrics, Gynecology è âîñïðîèçâîäñòâåííîé áèîëîãèè, øêîëû harvard ìåäèöèíñêîé
Ââåäåíèå:
Endometriosis áóäåò ïðèñóòñâèåì òêàíè ïîõîäèò íîðìàëüíîå endometrium íà ìåñòå âíå uterus. Àíàòîìè÷åñêèìè îáëàñòÿìè ñàìî îáù affected endometriosis áóäóò çàâÿçÿìè, òàçîâîé áðþøèíîé, uterosacral ëèãàìåíòàìè, ôàëëîïèåâûìè ïðîáêàìè, ïðèëîæåíèåì è serosa êèøå÷íèêà. Endometriomas, èëè «öèñòû øîêîëàäà» áóäóò öèñòàìè endometriosis âíóòðè çàâÿçü. «çîëîòîéà ñòàíäàðò» äëÿ äèàãíîñòèðóÿ endometriosis áóäåò laparoscopy, ñ âèçóàëüíî îïîçíàâàíèåì óáûòîêîâ endometriosis. Ñóðîâîñòü endometriosis îïðåäåëåíà àìåðèêàíñêèì îáùåñòâîì äëÿ âîñïðîèçâîäñòâåííîé ìèêñòóðû èñïîëüçóþù õèðóðãè÷åñêóþ ñèñòåìó ñöåíû îñíîâàííóþ íà ðàçìåðå è ïîëîæåíèå endometriosis èìïëàíòèðóåò è ñóðîâîñòü òàçîâûé íàíîñèòü øðàì. Ýòàïû ÿâëÿþòñÿ ñëåäóþùèìè: Ïîñòàâüòå ß-minimal6nuh, ýòàï Ii-22$$ET-slaby1, ïîñòàâüòå CIii-22$$ET-vmeru è ýòàï ÈÂ-strogie.
Ðàñïðîñòðàíèìîñòü è ïàäåíèå endometriosis íàèëó÷øèì îáðàçîì íå áûëè îõàðàêòåðèçîâàíû. Ðàñïðîñòðàíèìîñòü endometriosis íàõîäèòñÿ âåðîÿòíî â ðÿäå 5% èç æåíùèí âîñïðîèçâîäñòâåííîãî âðåìåíè (îò 13 äî 50 ëåò âðåìåíè). Ïèêîâîå ïàäåíèå ïðèáëèçèòåëüíî îò 25 äî 30 ëåò âðåìåíè. Ãîðìîíàëüíûå (ýñòðîãåí), ìåõàíè÷åñêè (ðåòðîãðàäíûé menstruation) è èììóíîëîãè÷åñêèå ôàêòîðû èãðàþò âàæíûå ðîëè â ýòèîëîãèè endometriosis. Óáûòîêè Endometriosis çàâèñÿò ñîâåðøåííî íà ýñòðîãåíå äëÿ âûæèâàíèÿ è ðîñòà.  îòñóòñòâèè ýñòðîãåíà, óáûòîêè endometriosis ðåãðåññèðóþò. Interventions óìåíüøàþò ïðîäóêöèþ ýñòðîãåíà, such as õèðóðãè÷åñêîå óäàëåíèå îáðàáîòêè çàâÿçåé èëè èíêðåòè ñ àíàëîãîì GnRH, ñâÿçàíû ñ óëó÷øåíèåì â òàçîâîé áîëè â áîëüøèíñòâ æåíùèíàõ ñ endometriosis. Ïîâåðåíû, ÷òî áóäåò ðåòðîãðàäíûé menstruation æèçíåñïîñîáíûõ endometrial êëåòîê îò uterus â òàçîâóþ ïîëîñòü âàæíûé «ìåõàíè÷åñêè ôàêòîð» ÷òî áóäåò íà÷èíàòü ñëó÷àåì â ðàçâèòèè endometriosis. Æåíùèíû ñ ñòðîãèì ñòåíîçîì öåðâèêàëüíîãî os è äåéñòâóÿ menstruate endometrium â ðåòðîãðàäíîé çàäíåé ÷àñòè îáðàçà ÷åðåç ôàëëîïèåâû ïðîáêè â òàçîâóþ ïîëîñòü. Ýòè æåíùèíû íà÷èíàþò endometriosis â ïî÷òè 100% èç ñëó÷àåâ.  ìåõàíèçìàõ íîðìàëüíûõ æåíùèí èììóíîëîãè÷åñêèõ âåðîÿòíî ÿñíûõ ìàëîå êîëè÷åñòâî endometrium, êîòîðîå äîñòèãàåò òàçîâóþ ïîëîñòü îò ðåòðîãðàäíîãî menstruation.  æåíùèíàõ ñ endometriosis áóäåò êîñâåííî äîêàçàòåëüñòâî ÷òî íåíîðìàëüíîñòè â èììóííîé ñèñòåìå óìåíüøàþò íîðìàëüíûé çàçîð endometrium âõîäèò â òàçîâóþ ïîëîñòü ÷åðåç ðåòðîãðàäíûé menstruation. Èñòîðèÿ ñåìüè endometriosis ñâÿçàíà ïðè ðèñê óâåëè÷åííûé 2-fold, ïðåäëàãàÿ ãåíåòè÷åñêîå predisposition.
Áîëüøèíñòâ æåíùèíû ñ endometriosis ïðåäñòàâëÿþò äëÿ ìåäèöèíñêîãî îáñëóæèâàíèÿ ñ «ãëàâíîé æàëîáîé» òàçîâîé áîëè, íåïëîäîðîäíîñòè, infertility and/or an ìàññû (îâàðèàëüíîãî endometrioma).
Öèñòû Endometriomas — Endometriosis çàâÿçè:
Endometriomas áóäåò benign öèñòàìè endometriosis çàâÿçè. Endometriomas áóäåò ìîíîêëîíàëüíûìè òóìîðàìè. Ìîíîêëîíàëüíàÿ ïðèðîäà endometriomas ïðåäëàãàåò ÷òî îíè âîçíèêàþò îò ñîìàòè÷åñêîé ïåðåãëàñîâêè â êëåòêå ïðåêóðñîðà. Íèêàêàÿ ìåäèöèíñêàÿ òåðàïèÿ íå èìååò â ðàñïîðÿæåíèè îáðàáîòàòü endometriomas. Endometriomas òèïè÷íî ïðåäñòàâëÿåò êàê adnexal ìàññû palpable íà ôèçè÷åñêîì exam èëè îáíàðóæåííûå íà òàçîâîì óëüòðàçâóêå.  gynecology, îáùèÿ íîðìû òî óïîðíåéøåå, ñëîæíûå adnexal ìàññû êîòîðûå áîëüøëå ÷åì 3 ñàíòèìåòðà (êàê îáóñëîâëåíî òàçîâûì óëüòðàçâóêîì) äîëæåí õèðóðãè÷åñêè áûòü ïðîèñâåäåí ðåçåêöèþ. Îñíîâîé ýòîò îáùèÿ íîðìû áóäåò òî õèðóðãè÷åñêîå óäàëåíèå ñîâñåì áîëüøîãî, óïîðíåéøå, ñëîæíî, îâàðèàëüíûå öèñòû óâåëè÷àò îáíàðóæåíèå è ýôôåêòèâíóþ îáðàáîòêó îâàðèàëüíîãî ðàêà íà ïðåäûäóùåì ýòàïå. Îâàðèàëüíûé ðàê, leading ïðè÷èíà ñìåðòè, ìîæíî òîëüêî óñïåøíî îáðàáîòàòü êîãäà îáíàðóæåíî íà ïðåäûäóùåì ýòàïå. Õèðóðãè÷åñêàÿ ðåçåêöèÿ endometrioma îáðàáîòàåò òóìîð è îáåñïå÷èò îêîí÷àòåëüíûé ïàòîëîãè÷åñêèé äèàãíîç (äîêàçûâàÿ ÷òî ýòî íå áóäåò îâàðèàëüíûì ðàêîì). Ïîñëå õèðóðãèè, îêîëî 10% èç æåíùèí íà÷èíàþò âòîðîå endometrioma. Ïîñëå õèðóðãè÷åñêîé îáðàáîòêè endometrioma, äîëãîñðî÷íàÿ îáðàáîòêà ñ êîíòðàöåïòèâîì ýñòðîãåí-progestina óñòíî óìåíüøàåò ðèñê ðåöèäèâèðîâàíèÿ óáûòîêîâ endometriosis â çàâÿçè.  æåíùèíàõ íå çàâåðøàëè èõ ñåìüþ, ïðåäîõðàíåíèå íîâûõ óáûòîêîâ endometriosis â çàâÿçè çàùèùàåò áóäóùóþ ïëîäîðîäíîñòü ïóòåì óìåíüøåíèå ðèñêà ïîòðåáíîñòè äëÿ äîïîëíèòåëüíîé îâàðèàëüíîé õèðóðãèè.
Íåïëîäîðîäíîñòü:
Îïðåäåëåíà íåïëîäîðîäíîñòü ïî ìåðå òîãî êàê íåâîçìîæíîñòü ïàðû äîñòèãíóòü ñòåëüíîñòè ïîñëå ïûòàòüñÿ íà 12 ìåñÿöà. Îáðàáîòêà íåïëîäîðîäíîñòè ñëîæíà, è â áîëüøèíñòâ ñèòóàöèÿõ, ïàðû ñ íåïëîäîðîäíîñòüþ äîëæíû áûòü ñîñëàíû ê ñïåöèàëèñòàì ïî íåïëîäîðîäíîñòè äëÿ îöåíêè è îáðàáîòêè. There is evidence that íåìåäëåííî íàïðàâëåíèå áåñïëîäíàÿà ñóïðóæåñêàÿ ïàðà ê ñïåöèàëèñòó ïî íåïëîäîðîäíîñòè ïðèâîäèò ê â ìåíüøå ïîòðåáëåíèè ðåñóðñà ÷åì êàðòèíà íàïðàâëåíèÿ îò ãëàâíûì îáðàçîì âðà÷à âíèìàòåëüíîñòè ê âîîáùå gynecologist è ïîñëå ýòîãî îêîí÷àòåëüíî ê ñïåöèàëèñòó ïî íåïëîäîðîäíîñòè. Ñòàíäàðòíûé ïîäõîä ê ïåðâîíà÷àëüíî äèàãíîçó íåïëîäîðîäíîñòè äîëæåí âûïîëíèòü àíàëèç semen, äîêóìåíòèðîâàòü îâóëÿöèþ (ïðîãåñòåðîí ñûâîðîòêè, áàçàëüíóþ äèàãðàììó òåìïåðàòóðû òåëà), è ïðîäåìîíñòðèðîâàòü patency ôàëëîïèåâûõ ïðîáîê (hysterosalpingogram). Åñëè ïåðâîíà÷àëüíî rabotaht-vverx áåñïëîäíàÿà ñóïðóæåñêàÿ ïàðà äåìîíñòðèðóþò íîðìàëüíóþ ovulatory ôóíêöèþ, íîðìàëüíûé àíàëèç semen è ïàòåíòóþò ôàëëîïèåâû ïðîáêè, òî áóäåò øàíñ 40% ÷òî æåíñêèé ñîó÷àñòíèê èìååò endometriosis. Ïîñëåäîâàòåëüíàÿ îáðàáîòêà ýòèõ æåíùèí ÷àñòî âêëþàåò îäíó õèðóðãè÷åñêóþ ïðîöåäóðó äëÿ òîãî ÷òîáû îáóñëîâèòü åñëè endometriosis ïðèñóòñòâóåò. Åñëè laparoscopy äåìîíñòðèðóåò ïðèñóòñâèå endometriosis, òî ïîïûòêó ïðîèñâåñòè ðåçåêöèþ âñåì óáûòîêàì è ïðèëèïàíèÿì ìîæíî âûïîëíèòü íà òàêîé æå õèðóðãèè. Åñëè õèðóðãèÿ íå ïîñëåäîâàíà çà ñòåëüíîñòüþ â ïðåäåëàõ ñëåäóþùèõ 12 ìåñÿöåâ, òî ýïèðè÷åñêàÿ èíäóêöèÿ ìóëòè-follikul4rno1 îâóëÿöèè ñ clomiphene èëè gonadotropins in combination with âíóòðèóòðîáíîå îñåìåíåíèå îáù ïîðåêîìåíäîâàíà. Åñëè ýòîò ïîäõîä íå ýôôåêòèâí, òî IVF òèïè÷íî ïîðåêîìåíäîâàíî (òàáëèöà 1). Ýòîò ïîäõîä ê îáðàáîòêå íåïëîäîðîäíîñòè ñâÿçàë ñ endometriosis îïèñàí áîëåå ïîäðîáíî íèæå.
Áîëüøàÿ êëèíè÷åñêàÿ ïðîáà ïðîäåìîíñòðèðîâàëà ÷òî õèðóðãè÷åñêàÿ îáðàáîòêà (ýêñöèçèÿ èëè óäàëåíèå) endometriosis óëó÷øàåò ïëîäîðîäíîñòü â ìàëîïëîäîðîäíûõ æåíùèíàõ ñ endometriosis.  ýòîì èçó÷åíèè, 341 ìàëîïëîäîðîäíîé æåíùèíå ñ ýòàïîì iim èëè II endometriosis áûëî õàîòèçèðîâàíî äëÿ òîãî ÷òîáû èìåòü äèàãíîñòè÷åñêèé laparoscopy èëè äèàãíîñòè÷åñêèé laparoscopy ñîâìåùåííûå ñ õèðóðãè÷åñêèìè ðåçåêöèåé èëè óäàëåíèåì óáûòîêîâ endometriosis. Âî âðåìÿ 36 íåäåëåé ïîñëåîïåðàöèîííîãî ïðîñëåæèâàíèÿ, 18% èç æåíùèí â äèàãíîñòè÷åñêîé ãðóïïå laparoscopy ñòàëî ñóïîðîñîé è 31% èç æåíùèí â äèàãíîñòè÷åñêîì laparoscopy ïëþñ ýêñöèçèÿ èëè óäàëåíèå ãðóïïû óáûòîêîâ endometriosis ñòàëî ñóïîðîñîé (ï<0.006). This well designed clinical trial suggests that surgical resection of endometriosis lesions can improve fertility in infertile women with endometriosis. However, pelvic surgery can cause pelvic adhesions, which can reduce fertility potential. Therefore, in the opinion of this author, infertile women should not have multiple operations to treat endometriosis lesions that are believed to be causing infertility. If the first adequate and complete operation is not followed by pregnancy during the next 12 months, then empirical induction of multi-follicular ovulation with clomiphene or gonadotropins in combination with intrauterine insemination is commonly recommended.
Êëèíè÷åñêèå ïðîáû ïðåäëàãàþò ÷òî îáðàáîòêà íåïëîäîðîäíîñòè ñ èíäóêöèåé ìóëòè-follikul4rno1 îâóëÿöèè ñ clomiphene èëè gonadotropins in combination with âíóòðèóòðîáíîå îñåìåíåíèå ýôôåêòèâíà â îáðàáàòûâàÿ íåïëîäîðîäíîñòè ñâÿçàííîé ñ endometriosis. Fedele è êîëëåãàû õàîòèçèðîâàëè 40 æåíùèí ñ ýòàïîì iim èëè endometriosis è íåïëîäîðîäíîñòüþ ýòàïà II äî 3 öèêëà ëþäñêèõ menopausal âïðûñîê gonadotropin (lh è FSH-Pergonal, Repronex) ïëþñ âíóòðèóòðîáíîå îñåìåíåíèå (IUI) èëè ê íèêàêîé îáðàáîòêå. Âïðûñêè lh è FSH íàâîäÿò ìóëòè-follikul4rnuh îâóëÿöèþ. Òàðèô ñòåëüíîñòè â öèêë áûë 4.5% â ãðóïïå îáðàáîòêè íåò è 15% â ãðóïïå LH-FSH-IUI (ï<0.05). In a large randomized clinical trial, 932 women with infertility, many of whom had endometriosis, were randomized to receive intracervical sperm insemination (ICI) alone, intrauterine insemination (IUI), FSH (Gonal-F, Follistim) injections plus intracervical sperm insemination or FSH injections plus intrauterine insemination. Intracervical sperm insemination (ICI) was designed as a "control" that would resemble the effects of natural intercourse. Intrauterine insemination (IUI) is a commonly used fertility treatment where an ejaculated semen specimen is treated in the laboratory to concentrate the sperm in a small volume of buffer while removing all the semen. The concentrated sperm pellet is then delivered to the upper portion of the uterine cavity with a small catheter passed through the cervix. ICI and IUI are timed to occur just before ovulation with the use of urine LH detection kits. FSH injections are given to stimulate multi-follicular ovulation. After 4 treatment cycles, the pregnancy rate in each group was: FSH plus IUI-33%, FSH plus the control ICI treatment- 19%, IUI alone 18%, the control ICI treatment alone 10% (p<0.01). This study demonstrates that FSH plus IUI or FSH plus ICI, or IUI alone improves pregnancy rate over an intervention designed to simulate intercourse alone (ICI). A major complication associated with the FSH injections was twin and triplet pregnancy. The maternal and fetal risks associated with triplet pregnancy may diminish the clinical utility of FSH injections in this infertility setting. Compared to FSH, clomiphene (Serophene, Clomid) ovulation induction is associated with fewer twin and triplet pregnancies. Clomiphene plus IUI therapy may result in a better balance of benefits (pregnancy) and risks (triplet pregnancy) than FSH plus IUI therapy.
Îáðàáîòêîé íåïëîäîðîäíîñòè, êîòîðàÿ èìååò áîëüøîé efficacy â æåíùèíàõ ñ endometriosis, áóäåò in vitro çåìëåóäîáðåíèåì è ïåðåõîäîì çàðîäûøà (IVF). IVF ñâÿçàíî ñ 30% â òàðèô ñòåëüíîñòè öèêëà â îáðàáîòêå íåïëîäîðîäíîñòè ïðè÷èíåííîé endometriosis.  ìíîãî öåíòðîâ, åñëè õèðóðãèÿ, ïîñëåäîâàííàÿ çà ÈÓÈ ñàìîñòîÿòåëüíî, ïîñëåäîâàëà çà ìóëòè-follikul4rno1 èíäóêöèåé îâóëÿöèè ïëþñ òåðïåòü íåóäà÷ó IUI äëÿ òîãî ÷òîáû ïðèâåñòè ê â ñòåëüíîñòè, òî IVF ïîðåêîìåíäîâàíî.  íåêîòîðûõ öåíòðàõ, IVF ïðåäëîæåíî íà «áûñòðîì êëèíè÷åñêîì ñëåäå» êàê ïåðâàÿ èíòåðâåíöèÿ â óñòàíîâêå endometriosis è íåïëîäîðîäíîñòè, ñïåöèàëüíî åñëè ìàëîïëîäîðîäíàÿ æåíùèíà áîëüøå ÷åì 37 ëåò âðåìåíè.  ïðàêòèêå àâòîðà, ìàëîïëîäîðîäíûå æåíùèíû < 32 years of age have the time to progress in a deliberate manner through all the standard treatment steps: surgery, IUI alone, clomiphene plus IUI, FSH injections plus IUI and finally IVF. For infertile women > 37 ëåò âðåìåíè, ïîêàçàíû, ÷òî èçáåãàåò áûñòðî ïðîãðåññèðîâàíèå ê IVF âîçìîæíîñòè ÷òî áóäóò èñòîùåíû âñå «çäîðîâûå» ôîëëèêóëû ïðåæäå ÷åì ñòåëüíîñòü áóäåò äîñòèãàíà.
Òàçîâàÿ Áîëü — Òðàäèöèîííûé Ïîäõîä:
Ìíîãî æåíùèí ñ endometriosis ïðåäñòàâëÿþò ñ òàçîâîé áîëüþ, âêëþ÷àÿ ñòðîãîå dysmenorrhea, dyspareunia, dyschezia è ïîíèæàþò ïîäáðþøíóþ áîëü îòíåñåííóþ ê menses. Ñòàíäàðòíûé ïîäõîä ê æåíùèíå ñ ñòðîãîé òàçîâîé áîëüþ, êîòîðàÿ íå èìåëà çíà÷èòåëüíî ñáðîñ áîëè ïîñëå òîãî êàê îíà îáðàáàòûâàíà ñ NSAIDs è óñòíî êîíòðàöåïòèâàìè, äîëæåí âûïîëíèòü laparoscopy äëÿ òîãî ÷òîáû îáóñëîâèòü ïðè÷èíó áîëè è óâèäåòü åñëè endometriosis ïðèñóòñòâóåò. Ïðåèìóùåñòâî óñòàíàâëèâàòü õèðóðãèþ â öåíòðàëüíîì ïîëîæåíèè â äèàãíîçå è îáðàáîòêå æåíùèí ñ òàçîâîé áîëüþ ÷òî îêîí÷àòåëüíûé äèàãíîç ìîæíî ÷àñòî îáóñëîâëèâàòü è åñëè endometriosis ïðîäåìîíñòðèðîâàíî, òî, õèðóðãè÷åñêàÿ ðåçåêöèÿ óáûòîêîâ ìîæåò ïðîèçâåñòè çíà÷èòåëüíî ñáðîñ áîëè äëÿ 12 ìåñÿöåâ èëè áîëüøå.  îäíîé õàîòèçèðîâàííîé controlled êëèíè÷åñêîé ïðîáå, õèðóðãè÷åñêàÿ ðåçåêöèÿ óáûòîêîâ endometriosis áûëà ïðîäåìîíñòðèðîâàíà ê ñáðîñó áîëè ïðîäóêöèè íà up to 12 ìåñÿöà ïîñëåîïåðàöèîííî.  ýòîì èçó÷åíèè, «àêòèâíî» õèðóðãè÷åñêàÿ ïðîöåäóðà ñîñòîÿëà äèàãíîñòè÷åñêîãî laparoscopy ñîâìåùåííîãî ñ óäàëåíèåì ëàçåðà óáûòîêîâ endometriosis ïëþñ óòðîáíîå óäàëåíèå íåðâà. Ìåòîäèêîé «ïðîâåðêè» õèðóðãè÷åñêîé áûë äèàãíîñòè÷åñêèé laparoscopy ïëþñ óñòðåìëåííîñòü òàçîâîé ïåðèòîíåàëüíîé æèäêîñòè. Âðà÷è îöåíèâàëè ðåàêöèþ ïàöèåíòîâ è ïàöèåíòîâ íå áûëè informed as to whether áûëà âûïîëíåíà äåÿòåëüíîñòü «àêòèâíî» èëè «óïðàâëåíèÿ».  ýòîì õàîòèçèðîâàííîì èçó÷åíèè, àêòèâíî õèðóðãè÷åñêàÿ ïðîöåäóðà ïðèâåëà ê â óëó÷øåíèè â áîëè â 63% èç æåíùèí è ìåòîäèêà ïðîâåðêè ïðèâåëà ê â óëó÷øåíèè â áîëè â 23% èç æåíùèí íà 6 ìåñÿöàõ ïðîñëåæèâàíèÿ (ï<0.01). This study suggests that surgical treatment of endometriosis can be effective in the treatment of pain.
Íåäàâíèå êëèíè÷åñêèå ïðîáû ïðåäëàãàþò ÷òî ïîñëå õèðóðãè÷åñêîé îáðàáîòêè endometriosis, òåðàïèÿ èíêðåòè íà 6 ìåñÿöåâ ñ àãîíèñòîì GnRH çàäåðæèâàåò ðåöèäèâèðîâàíèå òàçîâîé áîëè ê 12 ìåñÿöà.  îäíîé êëèíè÷åñêîé ïðîáå, 109 æåíùèí ñ laparoscopically äîêàçàííûì endometriosis, êîòîðîå ïðîøëî laparoscopic îáðàáîòêó óáûòîêîâ endometriosis, áûëè õàîòèçèðîâàíû äëÿ òîãî ÷òîáû ïîëó÷èòü èëè àíàëîã ÃíÐÞ-agonista, nafarelin (Synarel) insufflation 200 ug íîñîâîå twice daily èëè insufflation ïëàöåáà íîñîâîå twice daily íà 6 ìåñÿöåâ ïîñëåîïåðàöèîííî. Ãëàâíîé ïåðåìåþþûì èñõîäà áûëî ìåäèàííîå âðåìÿ ïîñëå îáðàáîòêè ê íà÷àëó äðóãîé òåðàïèè, êîòîðàÿ îòðàæàåò ðåöèäèâèðîâàíèå ñòðîãîé òàçîâîé áîëè. Æåíùèíû áûëè îáðàáîòàíû ñ nafarelin ïîñëåîïåðàöèîííî èìåëè ìåäèàííîå âðåìÿ ê íà÷àëó äðóãîé òåðàïèè > 24 ìåñÿöà.  ãðóïïå îáðàáîòàííîé ñ ïëàöåáîì ìåäèàííîå âðåìÿ ê íà÷àëó äðóãîé òåðàïèè áûëî 12 ìåñÿöà (ï<0.001). Ýòî çàíÿòèå ïðåäëàãàåò, ÷òî êîìáèíàöèÿ õèðóðãèè ïëþñ øåñò- ðàáî÷èå ãîðìîí òåðàïèÿ ìîãó áûòü ïîëåçíûå in ïðîäëåâàòü ðàç â ðåêóððåíòíîñòü î òàçîâûå áîëü â æåíùèíû ñî [endometriosis.] Èíèöèàòîð ïðåäëàãàåò æåíùèíàì ñî [endometriosis] îòïðàâëÿòü- ñòàíî÷íèêó ãîðìîí òåðàïèþ, ñî èëè êîìáèíàöèþ ýñòðîãåí- progestin âñå ðîòîâîé êîíòðàöåïòèâ èëè GnRH agonist analogue.
Òàçîâàÿ áîëü — ïîëüçà «êëèíè÷åñêîãî äèàãíîçà» Endometriosis:
 íàñòîÿùåå âðåìÿ «çîëîòîéà ñòàíäàðò» äëÿ äèàãíîçà endometriosis áóäåò õèðóðãè÷åñêàÿ äîêóìåíòàöèÿ óáûòîêîâ endometriosis âèçóàëüíî îáíàðóæåíèåì. Ïðåèìóùåñòâà ýòîãî ïîäõîäà ÷òî î÷åíü ìàëîâåðîÿòíî ÷òî áóäåò ïðîïóùåíî èëè misdiagnosed ñåðüåçíîå ñîñòîÿíèå, such as îâàðèàëüíûé ðàê, è ÷òî îáðàáîòêà endometriosis ìîæåò îñóùåñòâèòü âî âðåìÿ õèðóðãè÷åñêîãî âèçóàëèçèðîâàíèÿ. Áóäóò íåñêîëüêî êëèíè÷åñêèå íåäîñòàòêè ê èñïîëüçîâàíèþ õèðóðãè÷åñêîãî âèçóàëèçèðîâàíèÿ óáûòîêîâ êàê «çîëîòîéà ñòàíäàðò» äëÿ äèàãíîçà endometriosis. Ýòè íåäîñòàòêè âêëþàþò: òðåáîâàíèå äëÿ õèðóðãèè è íàðêîòèçàöèè, âîçìîæíîñòè êîòîðóþ ìûñëüþ óáûòîêà, êîòîð áóäåò áûòü endometriosis èíñïåêöèîííûé îñìîòð íå ìîãëà äîêàçàòü äëÿ òîãî ÷òîáû áûòü endometriosis íà ãèñòîëîãè÷åñêîì àíàëèçå è âîçìîæíîñòè ÷òî íåêîòîðûå ãëóáîêèå óáûòîêè endometriosis ìîãëè áûòü òðóäíû äëÿ òîãî ÷òîáû âèçóàëèçèðîâàòü è ïîñëåäîâàòåëüí ïîñëå òîãî êàê îíè îáíàðóæåíû. Àëòåðíàòèâîé ê õèðóðãèè áóäåò ïîëüçà «êëèíè÷åñêîãî äèàãíîçà», îñíîâàííàÿ íà èñòîðèè, ôèçè÷åñêîå ðàññìîòðåíèå è íåèíâàçèâíûå ëàáîðàòîðíÿ èññëåäîâàíèå, äëÿ òîãî ÷òîáû ñäåëàòü äèàãíîç endometriosis. Íåäàâí îïóáëèêîâàííîå èçó÷åíèå ïîääåðæèâàåò ïðèíöèïèàëüíóþ ñõåìó äåëàòü «êëèíè÷åñêèé äèàãíîç» endometriosis â íåêîòîðûõ êëèíè÷åñêèõ ñèòóàöèÿõ, è èñïîëüçîâàíèÿ «ýïèðè÷åñêîé» îáðàáîòêè èíêðåòè äëÿ òàçîâîé áîëè ïðåäïîëàãàåìûå, ÷òî áûëî äîëæíî ê endometriosis.
Íåäàâíåå èçó÷åíèå ñôîêóñèðîâàëî íà 100 æåíùèíàõ ñ õðîíè÷åñêîé òàçîâîé áîëüþ ñîîòâåñòâîâàëà 13 êðèòåðÿì ïî âêëþ÷åíèÿ: 1) óìåðÿåò ê ñòðîãîé õðîíè÷åñêîé òàçîâîé áîëè, 2) âðåìÿ îò 18 äî 45 ëåò, 3) ðåãóëÿðíî ìåíñòðóàëüíûå öèêëû, 4) íèêàêîé ðàíåå äèàãíîç endometriosis õèðóðãè÷åñêîé ïðîöåäóðîé, 5) íèêàêàÿ îáðàáîòêà èíêðåòè âíóòðè çà 3 ìåñÿöàìè, 6) íèêàêîå äîêàçàòåëüñòâî äëÿ ãëàâíûì îáðàçîì çàáîëåâàíèÿ ìî÷åâûäåëèòåëüíîãî òðàêòà èëè êèøå÷íèê êàê ïðè÷èíà áîëè, 7) íèêàêàÿ èñòîðèÿ ÷ðåçìåðíî ïîëüçû ñïèðòà, ñíàäîáèü òðàíêâèëèçàòîðà èëè illicit ñíàäîáèü, 8) íîðìàëüíûé òàçîâûé óëüòðàçâóê, 9) íîðìàëüíûé âïîëíå îòñ÷åò êðîâè, 10) íîðìàëüíûé urinalysis, 11) îòñóòñòâèå gonorrhea è chlamydia íà èñïûòàíèÿõ endocervical îáðàçöà, 12) îòðèöàòåëüíîå èñïûòàíèå ñòåëüíîñòè, è 13) îòêàç íîí-non-steroidal anti-inflammatory ëåêàðñòâ è îáðàáîòêè doxycylcine óëó÷øèòü ñèìïòîìû áîëè.
Æåíùèíû áûëè õàîòèçèðîâàíû äëÿ òîãî ÷òîáû ïîëó÷èòü îáðàáîòêó ñ leuprolide äåïà (Lupron) 3.75 âïðûñêè ìàãíèÿ âíóòðèìûøå÷íûõ êàæäûå 4 íåäåëè íà 12 íåäåëè èëè ïîëó÷èòü âïðûñêó ïëàöåáà íà 12 íåäåëè. Áîëü áûëà èçìåðåíà ñ 4-point Biberoglu è ìàøòàáîì Behrman. Íà êîíöå îáðàáîòêè 12 íåäåëåé, âñå æåíùèíû ïðîøëè laparoscopy äëÿ òîãî ÷òîáû îïðåäåëèòü òî÷íîñòü «êëèíè÷åñêîãî äèàãíîçà» endometriosis. Íà êîíöå èçó÷åíèÿ, íà laparoscopy, áûëî îáóñëîâëåíî õèðóðãè÷åñêèì âèçóàëèçèðîâàíèåì óáûòîêîâ, êîòîðûì 87% èç æåíùèí â ãðóïïå ïëàöåáà è 78% æåíùèí â ãðóïïå leuprolide èìåëè endometriosis. Ýòî ïðåäëàãàåò ÷òî êðèòåðÿ ïî âêëþ÷åíèÿ 13 ïóíêòîâ ïåðå÷èñëåííàÿ âûøå îòíîñèòåëüíî ýôôåêòèâíà â îïðåäåëÿòü æåíùèí ñ õðîíè÷åñêîé òàçîâîé áîëüþ èìåþò endometriosis êàê ïðè÷èíà èõ áîëè (ïî êðàéíåé ìåðå â ýòîé íàñåëåííîñòè èçó÷åíèÿ). In addition, èçó÷åíèå ïîêàçàëî ÷òî 82% èç æåíùèí îáðàáîòàëî ñ ýïèðè÷åñêèì leuprolide èìåëî ñáðîñ áîëè áûòü ñðàâíåííûì äî 39% èç æåíùèí îáðàáîòàííûõ ñ ïëàöåáîì. Ýòîò ðåçóëüòàò ïîêàçûâàåò òî â æåíùèíàõ ñ êëèíè÷åñêèì äèàãíîçîì endometriosis, «ýïèðè÷åñêàÿ» îáðàáîòêà èíêðåòè ñ âïðûñêîé ìàãíèÿ äåïà 3.75 àöåòàòà leuprolide âíóòðèìûøå÷íîé êàæäûå 4 íåäåëè (Lupron) ñìîãèòå áûòü ýôôåêòèâí â ñáðàñûâàòü òàçîâóþ áîëü.
Ýòî èçó÷åíèå, è äðóãèå, ïîääåðæèâàþò ïðèíöèïèàëüíóþ ñõåìó äåëàòü êëèíè÷åñêèé äèàãíîç endometriosis îñíîâàííûé íà èñòîðèè, ôèçè÷åñêèõ çàêëþ÷åíèÿõ è ëèìèòèðîâàííîì ïî ïðîâåðêå ëàáîðàòîðèè. Æåíùèí êëèíè÷åñêè äèàãíîñòèðîâàííûå ñ endometriosis ìîæíî ïîñëå ýòîãî ïðåäëîæèòü îáðàáîòêó ñ àíàëîãîì GnRH, danazol èëè ïðîãåñòèíîì äëÿ èõ òàçîâîé áîëè. Íåäàâíèé àìåðèêàíñêèé êîëëåæ òåõíè÷åñêèé áþëëåòåíü obstetricians è gynecologists, «ìåäèöèíñêîå óïðàâëåíèå Endometriosis», îáñóäèë ýòó ýâîëþöèîíèðóÿ êëèíè÷åñêóþ ïàðàäèãìó è çàêëþ÷èë ÷òî êëèíè÷åñêèé äèàãíîç endometriosis è ýïèðè÷åñêîé îáðàáîòêè èíêðåòè ìîæåò áûòü efficacious.
Hysterectomy è äâóõñòîðîííèé oophorectomy:
Áûëè ñîîáùåíû, ÷òî îáåñïå÷èâàþò hysterectomy è äâóõñòîðîííèé oophorectomy (TAH_BSO) äîëãîñðî÷íûé ñáðîñ áîëè â ïðèáëèçèòåëüíî 85% èç æåíùèí ñ endometriosis. Îáðàáîòêà TAH-BSO òîëüêî èìåþùÿÿñÿ ê æåíùèíàì îïðåäåëåííî çàâåðøàëè èõ ñåìüþ. Ïîñëå TAH-BSO, òåðàïèÿ çàìåíû èíêðåòè ñ ñòàíäàðòíûìè ðåæèìàìè ìîæåò îáðàáîòàòü âàçîìîòîðíûå ñèìïòîìû áåç óâåëè÷èâàòü ðèñê ðåöèäèâèðîâàíèÿ endometriosis è òàçîâîé áîëè. Øèðîêîìàñøòàáíûå ïðîáû ïðîñëåæèâàíèÿ ïîêàçûâàþò ÷òî æåíùèíû ñ endometriosis è ñòðîãîé òàçîâîé áîëüþ áûëè îáðàáîòàíû ñ TAH-BSO èìåþò äîëãîñðî÷íîå óëó÷øåíèå â èõ ñèìïòîìàõ áîëè è óäîâëåòâîðÿþòñÿ ñ èõ âûáîðîì îáðàáîòêè.
Ìåäèöèíñêÿ ëå÷åíèå òàçîâîé áîëè ïðè÷èíåííûé Åíäîìåòðèîñèñ:
Æåíùèí ñ endometriosis è òàçîâîé áîëüþ ìîæíî óñïåøíî îáðàáîòàòü ñ òåðàïèåé èíêðåòè. Ïðàêòèêà àâòîðà äîëæíà íà÷àòü ñ îáðàáîòêàìè èíêðåòè ñ íåìíîãèìè ïîáî÷íûìè ýôôåêòàìè (íîí-non-steroidal anti-inflammatory âåùåñòâàìè èñïîëüçóåìûìè íà ïî÷òè maximal äîçàõ, óñòíî êîíòðàöåïòèâàõ èñïîëüçóåìûõ â öèêëîâîì èëè íåïðåðûâíîì îáðàçå) è ïîñëå ýòîãî ðàçâèòü ïîñëåäîâàòåëüí äëÿ èñïîëüçîâàíèÿ áîëåå ìîùíûõ îáðàáîòîê èíêðåòè êîòîðûå ñâÿçàíû ñ çíà÷èòåëüíî ïîáî÷íûìè ýôôåêòàìè (àíàëîãàìè GnRH such as nafarelin è leuprolide, danazol). Ýòî ïðîãðåññèðîâàíèå êîíñïåêòèðîâàíî â òàáëèöå 2.
Êàæåòñÿ, ÷òî áóäåò êîíòðàöåïòèâ ñòàíäàðòíîãî ýñòðîãåí-progestina êîìáèíàöèè óñòíî ýôôåêòèâí â îáðàáîòêå òàçîâîé áîëè ïðè÷èíåííîé endometriosis. Ñòàíäàðòíàÿ óñòíî ïðîòèâîçà÷àòî÷íàÿ ïèëþëüêà ñîäåðæèò ïðîãåñòèí â êàæäîé ïèëþëüêå. Ïðîãåñòèí ïðåãðàæäàåò ðîñò â ìíîãî óáûòîêîâ endometriosis, â ÷àñòè, ïóòåì ïðåãðàæäàòü ðîñò ïîâûøàÿ ñâîéñòâà ýñòðîãåíà.
Àëòåðíàòèâà ê ñòàíäàðòíîìó ïëàí-ãðàôèêó (21 ïèëþëüêå èíêðåòè, ïîñëåäîâàííîé çà ê 7 äíåé ñ ïèëþëüêè) äëÿ administering êîíòðàöåïòèâû ýñòðîãåí-progestina êîìáèíàöèè óñòíî äîëæíà ïðåäïèñàòü 63 àêòèâíî ïèëþëüêè èíêðåòè â ðÿäêå (3 ïàêåòàõ 21 àêòèâíî ïèëþëüêè) ïîñëåäîâàííîì çà ê 7 äíåé ñ ïèëþëüêè, ïîñëåäîâàííîé çà 63 àêòèâíî ïèëþëüêàìè â ðÿäêå. Ýòîò ïîäõîä áûë îïèñàí àâòîðîì êàê «minia4-pseudopregnancy» ïîòîìó ÷òî îí ÷àñòî ïðèâîäèò ê â menses êàæäûå 10 íåäåëåé rather than êàæäûõ 4 íåäåëÿõ. Äàæå äëèòåëüíûéà öèêë ìîæåò áûòü ïðåäïèñàí ïóòåì ðåêîìåíäîâàòü ïîëüçó 105 (5 ïàêåòîâ 21 àêòèâíî ïèëþëüêè) â ðÿäêå, ïîñëåäîâàííîì çà ê 7 äíåé ñ ëåêàðñòâà, ïîñëåäîâàííîãî çà 105 àêòèâíî ïèëþëüêàìè â ðÿäêå.  îäíîì èçó÷åíèè, æåíùèíû êîòîðûå áûëè ïîçâîëåíû ðàñøèðèòü ÷èñëî ïîñëåäîâàòåëüíûõ àêòèâíî ïèëþëåê è èçáåæàòü ïèëþëüêó ñâîáîäíî íåäåëÿ ñîîáùèëè âûñîêèé ñòåïåíü ñîîòâåòñòâèÿ ñ âûäâèíóòûì ðåæèìîì ïèëþëüêè. Ãëàâíûé íåäîñòàòîê ê ïîëüçå «äëèòåëüíûéà öèêë» ÷òî ìíîãî æåíùèí íà÷èíàþò «êðîâîòå÷åíèå ïðîðûâà» è èìåþò ìàëîå êîëè÷åñòâà óòðîáíîãî êðîâîòå÷åíèÿ, ÷àñòî ñîîáùàåìûå, ÷òî áûëè êîðè÷íåâû â öâåòå, ìíîãî äíåé â íåäåëþ. Ïðîëîìîì ÷åðåç êðîâîòå÷åíèå áóäåò æåíùèíû ãëàâíàÿà ïðè÷èíà èñïîëüçóÿ «miniuh-pseudopregnancy» ïðåðûâàåò ëåêàðñòâî.
Åñëè óñòíî êîíòðàöåïòèâû íå ýôôåêòèâíû ïîñëå ýòîãî, òî ïàöèåíòà ìîæíî îáðàáîòàòü ñ nafarelin (Synarel) 200 ug twice daily íîñîâûì äåïîì àöåòàòà insufflation èëè leuprolide (Lupron), âïðûñêîé ìàãíèÿ 3.75 âíóòðèìûøå÷íîé êàæäûå 4 íåäåëè. Ñòàíäàðòíûì êóðñîì îáðàáîòêè àãîíèñòà GnRH áóäåò 24 íåäåëè, íî ðåæèìû îáðàáîòêè êàê ñêîðî êàê áûëè ïîêàçàíû, ÷òî áóäóò 12 íåäåëè ýôôåêòèâíû. Àíàëîãè àãîíèñòà GnRH, nafarelin è leuprolide, ïåðâîíà÷àëüíî ñòèìóëèðóþò pituitary îòïóñê lh è FSH, íî ñ õðîíè÷åñêîé ïîëüçîé, îíè ïàðàäîêñàëüíî âíèç-reguliruet ñåêðåòèðîâàíèå lh è FSH, resulting in cessation îâàðèàëüíîãî ôîëëèêóëÿðíîãî ðîñòà è ïîäàâëåíèå îâàðèàëüíîé ïðîäóêöèè ýñòðîãåíà è ïðîãåñòèíà. Îòñóòñòâèå îâàðèàëüíîé ïðîäóêöèè ýñòðîãåíà è ïðîãåñòèíà, ïðèâîäèò ê â amenorrhea è hypoestrogenic ïîáî÷íûõ ýôôåêòàõ such as ãîðÿ÷èå âñïûøêè è óâåëè÷åííûé òàðèô ðåçîðáöèè êîñòî÷êè. Hypoestrogenism íàâåäåííîå àãîíèñòàìè GnRH ñâÿçàíî ñ ñáðîñîì òàçîâîé áîëè â ïðèáëèçèòåëüíî 85% èç æåíùèí ñ endometriosis. Ýòî ñèëüíîå ïîëîæèòåëüíîå âîçäåéñòâèå áûòü ñáàëàíñèðîâàííûì ïðîòèâ ïîáî÷íûõ ýôôåêòîâ ãîðÿ÷èõ âñïûøåê è ïîòåðè êîñòî÷êè. Äëÿ íåêîòîðûõ æåíùèí, ñáðîñ áîëè ïîýòîìó èìïðåññèâíî è ïîáî÷íî ýôôåêòû áóäüòå íàñòîëüêî ìèíèìàëüí ÷òî îíè õîòÿò îñòàòüñÿ íà îáðàáîòêå íà áîëåå äëèíîé ÷åì 6 ìåñÿöåâ. Ýòî áåçîïàñíî, åñëè êîíòðîëèðóþò ïàöèåíòà áûòü îñòîðîæíûì äëÿ ïîòåðè êîñòî÷êè. ñòåðîèä Íèçê-dozy «äîáàâëÿåò íàçàä» ìîæíî äîáàâèòü, ÷òî ê îáðàáîòêå àãîíèñòà GnRH óìåíüøèë òàðèô ïîòåðè êîñòî÷êè è îáðàáîòàë ãîðÿ÷èå âñïûøêè. Dobav6te-nazad ðåæèìû, êîòîðûå áûëè ïðîäåìîíñòðèðîâàíû, äëÿ òîãî ÷òîáû áûòü ýôôåêòèâí ïåðå÷èñëèòå â òàáëèöå 3. Ïîñëå discontinuation îáðàáîòêè, òàçîâàÿ áîëü êëîíèò ðåöèäèâèðîâàòü â áîëüøèíñòâ æåíùèíàõ íàä ñëåäóþùèìè 12 ìåñÿöàìè.
Printable Âàðèàíò
Endometriosis
Äð. Robert L Áàðáèåðè
Ïðîôåññîð Kate Macy Ladd obstetrics, Gynecology è âîñïðîèçâîäñòâåííîé áèîëîãèè, øêîëû harvard ìåäèöèíñêîé; Âîæäü obstetrics è Gynecology, Brigham è ñòàöèîíàðà æåíùèí; Ðóêîâîäèòåëü obstetrics, Gynecology è âîñïðîèçâîäñòâåííîé áèîëîãèè, øêîëû harvard ìåäèöèíñêîé
Ââåäåíèå:
Endometriosis áóäåò ïðèñóòñâèåì òêàíè ïîõîäèò íîðìàëüíîå endometrium íà ìåñòå âíå uterus. Àíàòîìè÷åñêèìè îáëàñòÿìè ñàìî îáù affected endometriosis áóäóò çàâÿçÿìè, òàçîâîé áðþøèíîé, uterosacral ëèãàìåíòàìè, ôàëëîïèåâûìè ïðîáêàìè, ïðèëîæåíèåì è serosa êèøå÷íèêà. Endometriomas, èëè «öèñòû øîêîëàäà» áóäóò öèñòàìè endometriosis âíóòðè çàâÿçü. «çîëîòîéà ñòàíäàðò» äëÿ äèàãíîñòèðóÿ endometriosis áóäåò laparoscopy, ñ âèçóàëüíî îïîçíàâàíèåì óáûòîêîâ endometriosis. Ñóðîâîñòü endometriosis îïðåäåëåíà àìåðèêàíñêèì îáùåñòâîì äëÿ âîñïðîèçâîäñòâåííîé ìèêñòóðû èñïîëüçóþù õèðóðãè÷åñêóþ ñèñòåìó ñöåíû îñíîâàííóþ íà ðàçìåðå è ïîëîæåíèå endometriosis èìïëàíòèðóåò è ñóðîâîñòü òàçîâûé íàíîñèòü øðàì. Ýòàïû ÿâëÿþòñÿ ñëåäóþùèìè: Ïîñòàâüòå ß-minimal6nuh, ýòàï Ii-22$$ET-slaby1, ïîñòàâüòå CIii-22$$ET-vmeru è ýòàï ÈÂ-strogie.
Ðàñïðîñòðàíèìîñòü è ïàäåíèå endometriosis íàèëó÷øèì îáðàçîì íå áûëè îõàðàêòåðèçîâàíû. Ðàñïðîñòðàíèìîñòü endometriosis íàõîäèòñÿ âåðîÿòíî â ðÿäå 5% èç æåíùèí âîñïðîèçâîäñòâåííîãî âðåìåíè (îò 13 äî 50 ëåò âðåìåíè). Ïèêîâîå ïàäåíèå ïðèáëèçèòåëüíî îò 25 äî 30 ëåò âðåìåíè. Ãîðìîíàëüíûå (ýñòðîãåí), ìåõàíè÷åñêè (ðåòðîãðàäíûé menstruation) è èììóíîëîãè÷åñêèå ôàêòîðû èãðàþò âàæíûå ðîëè â ýòèîëîãèè endometriosis. Óáûòîêè Endometriosis çàâèñÿò ñîâåðøåííî íà ýñòðîãåíå äëÿ âûæèâàíèÿ è ðîñòà.  îòñóòñòâèè ýñòðîãåíà, óáûòîêè endometriosis ðåãðåññèðóþò. Interventions óìåíüøàþò ïðîäóêöèþ ýñòðîãåíà, such as õèðóðãè÷åñêîå óäàëåíèå îáðàáîòêè çàâÿçåé èëè èíêðåòè ñ àíàëîãîì GnRH, ñâÿçàíû ñ óëó÷øåíèåì â òàçîâîé áîëè â áîëüøèíñòâ æåíùèíàõ ñ endometriosis. Ïîâåðåíû, ÷òî áóäåò ðåòðîãðàäíûé menstruation æèçíåñïîñîáíûõ endometrial êëåòîê îò uterus â òàçîâóþ ïîëîñòü âàæíûé «ìåõàíè÷åñêè ôàêòîð» ÷òî áóäåò íà÷èíàòü ñëó÷àåì â ðàçâèòèè endometriosis. Æåíùèíû ñ ñòðîãèì ñòåíîçîì öåðâèêàëüíîãî os è äåéñòâóÿ menstruate endometrium â ðåòðîãðàäíîé çàäíåé ÷àñòè îáðàçà ÷åðåç ôàëëîïèåâû ïðîáêè â òàçîâóþ ïîëîñòü. Ýòè æåíùèíû íà÷èíàþò endometriosis â ïî÷òè 100% èç ñëó÷àåâ.  ìåõàíèçìàõ íîðìàëüíûõ æåíùèí èììóíîëîãè÷åñêèõ âåðîÿòíî ÿñíûõ ìàëîå êîëè÷åñòâî endometrium, êîòîðîå äîñòèãàåò òàçîâóþ ïîëîñòü îò ðåòðîãðàäíîãî menstruation.  æåíùèíàõ ñ endometriosis áóäåò êîñâåííî äîêàçàòåëüñòâî ÷òî íåíîðìàëüíîñòè â èììóííîé ñèñòåìå óìåíüøàþò íîðìàëüíûé çàçîð endometrium âõîäèò â òàçîâóþ ïîëîñòü ÷åðåç ðåòðîãðàäíûé menstruation. Èñòîðèÿ ñåìüè endometriosis ñâÿçàíà ïðè ðèñê óâåëè÷åííûé 2-fold, ïðåäëàãàÿ ãåíåòè÷åñêîå predisposition.
Áîëüøèíñòâ æåíùèíû ñ endometriosis ïðåäñòàâëÿþò äëÿ ìåäèöèíñêîãî îáñëóæèâàíèÿ ñ «ãëàâíîé æàëîáîé» òàçîâîé áîëè, íåïëîäîðîäíîñòè and/or adnexal ìàññû (îâàðèàëüíîãî endometrioma).
Öèñòû Endometriomas — Endometriosis çàâÿçè:
Endometriomas áóäåò benign öèñòàìè endometriosis çàâÿçè. Endometriomas áóäåò ìîíîêëîíàëüíûìè òóìîðàìè. Ìîíîêëîíàëüíàÿ ïðèðîäà endometriomas ïðåäëàãàåò ÷òî îíè âîçíèêàþò îò ñîìàòè÷åñêîé ïåðåãëàñîâêè â êëåòêå ïðåêóðñîðà. Íèêàêàÿ ìåäèöèíñêàÿ òåðàïèÿ íå èìååò â ðàñïîðÿæåíèè îáðàáîòàòü endometriomas. Endometriomas òèïè÷íî ïðåäñòàâëÿåò êàê adnexal ìàññû palpable íà ôèçè÷åñêîì exam èëè îáíàðóæåííûå íà òàçîâîì óëüòðàçâóêå.  gynecology, îáùèÿ íîðìû òî óïîðíåéøåå, ñëîæíûå adnexal ìàññû êîòîðûå áîëüøëå ÷åì 3 ñàíòèìåòðà (êàê îáóñëîâëåíî òàçîâûì óëüòðàçâóêîì) äîëæåí õèðóðãè÷åñêè áûòü ïðîèñâåäåí ðåçåêöèþ. Îñíîâîé ýòîò îáùèÿ íîðìû áóäåò òî õèðóðãè÷åñêîå óäàëåíèå ñîâñåì áîëüøîãî, óïîðíåéøå, ñëîæíî, îâàðèàëüíûå öèñòû óâåëè÷àò îáíàðóæåíèå è ýôôåêòèâíóþ îáðàáîòêó îâàðèàëüíîãî ðàêà íà ïðåäûäóùåì ýòàïå. Îâàðèàëüíûé ðàê, leading ïðè÷èíà ñìåðòè, ìîæíî òîëüêî óñïåøíî îáðàáîòàòü êîãäà îáíàðóæåíî íà ïðåäûäóùåì ýòàïå. Õèðóðãè÷åñêàÿ ðåçåêöèÿ endometrioma îáðàáîòàåò òóìîð è îáåñïå÷èò îêîí÷àòåëüíûé ïàòîëîãè÷åñêèé äèàãíîç (äîêàçûâàÿ ÷òî ýòî íå áóäåò îâàðèàëüíûì ðàêîì). Ïîñëå õèðóðãèè, îêîëî 10% èç æåíùèí íà÷èíàþò âòîðîå endometrioma. Ïîñëå õèðóðãè÷åñêîé îáðàáîòêè endometrioma, äîëãîñðî÷íàÿ îáðàáîòêà ñ êîíòðàöåïòèâîì ýñòðîãåí-progestina óñòíî óìåíüøàåò ðèñê ðåöèäèâèðîâàíèÿ óáûòîêîâ endometriosis â çàâÿçè.  æåíùèíàõ íå çàâåðøàëè èõ ñåìüþ, ïðåäîõðàíåíèå íîâûõ óáûòîêîâ endometriosis â çàâÿçè çàùèùàåò áóäóùóþ ïëîäîðîäíîñòü ïóòåì óìåíüøåíèå ðèñêà ïîòðåáíîñòè äëÿ äîïîëíèòåëüíîé îâàðèàëüíîé õèðóðãèè.
Íåïëîäîðîäíîñòü:
Îïðåäåëåíà íåïëîäîðîäíîñòü ïî ìåðå òîãî êàê íåâîçìîæíîñòü ïàðû äîñòèãíóòü ñòåëüíîñòè ïîñëå ïûòàòüñÿ íà 12 ìåñÿöà. Îáðàáîòêà íåïëîäîðîäíîñòè ñëîæíà, è â áîëüøèíñòâ ñèòóàöèÿõ, ïàðû ñ íåïëîäîðîäíîñòüþ äîëæíû áûòü ñîñëàíû ê ñïåöèàëèñòàì ïî íåïëîäîðîäíîñòè äëÿ îöåíêè è îáðàáîòêè. There is evidence that íåìåäëåííî íàïðàâëåíèå áåñïëîäíàÿà ñóïðóæåñêàÿ ïàðà ê ñïåöèàëèñòó ïî íåïëîäîðîäíîñòè ïðèâîäèò ê â ìåíüøå ïîòðåáëåíèè ðåñóðñà ÷åì êàðòèíà íàïðàâëåíèÿ îò ãëàâíûì îáðàçîì âðà÷à âíèìàòåëüíîñòè ê âîîáùå gynecologist è ïîñëå ýòîãî îêîí÷àòåëüíî ê ñïåöèàëèñòó ïî íåïëîäîðîäíîñòè. Ñòàíäàðòíûé ïîäõîä ê ïåðâîíà÷àëüíî äèàãíîçó íåïëîäîðîäíîñòè äîëæåí âûïîëíèòü àíàëèç semen, äîêóìåíòèðîâàòü îâóëÿöèþ (ïðîãåñòåðîí ñûâîðîòêè, áàçàëüíóþ äèàãðàììó òåìïåðàòóðû òåëà), è ïðîäåìîíñòðèðîâàòü patency ôàëëîïèåâûõ ïðîáîê (hysterosalpingogram). Åñëè ïåðâîíà÷àëüíî rabotaht-vverx áåñïëîäíàÿà ñóïðóæåñêàÿ ïàðà äåìîíñòðèðóþò íîðìàëüíóþ ovulatory ôóíêöèþ, íîðìàëüíûé àíàëèç semen è ïàòåíòóþò ôàëëîïèåâû ïðîáêè, òî áóäåò øàíñ 40% ÷òî æåíñêèé ñîó÷àñòíèê èìååò endometriosis. Ïîñëåäîâàòåëüíàÿ îáðàáîòêà ýòèõ æåíùèí ÷àñòî âêëþàåò îäíó õèðóðãè÷åñêóþ ïðîöåäóðó äëÿ òîãî ÷òîáû îáóñëîâèòü åñëè endometriosis ïðèñóòñòâóåò. Åñëè laparoscopy äåìîíñòðèðóåò ïðèñóòñâèå endometriosis, òî ïîïûòêó ïðîèñâåñòè ðåçåêöèþ âñåì óáûòîêàì è ïðèëèïàíèÿì ìîæíî âûïîëíèòü íà òàêîé æå õèðóðãèè. Åñëè õèðóðãèÿ íå ïîñëåäîâàíà çà ñòåëüíîñòüþ â ïðåäåëàõ ñëåäóþùèõ 12 ìåñÿöåâ, òî ýïèðè÷åñêàÿ èíäóêöèÿ ìóëòè-follikul4rno1 îâóëÿöèè ñ clomiphene èëè gonadotropins in combination with âíóòðèóòðîáíîå îñåìåíåíèå îáù ïîðåêîìåíäîâàíà. Åñëè ýòîò ïîäõîä íå ýôôåêòèâí, òî IVF òèïè÷íî ïîðåêîìåíäîâàíî (òàáëèöà 1). Ýòîò ïîäõîä ê îáðàáîòêå íåïëîäîðîäíîñòè ñâÿçàë ñ endometriosis îïèñàí áîëåå ïîäðîáíî íèæå.
Áîëüøàÿ êëèíè÷åñêàÿ ïðîáà ïðîäåìîíñòðèðîâàëà ÷òî õèðóðãè÷åñêàÿ îáðàáîòêà (ýêñöèçèÿ èëè óäàëåíèå) endometriosis óëó÷øàåò ïëîäîðîäíîñòü â ìàëîïëîäîðîäíûõ æåíùèíàõ ñ endometriosis.  ýòîì èçó÷åíèè, 341 ìàëîïëîäîðîäíîé æåíùèíå ñ ýòàïîì iim èëè II endometriosis áûëî õàîòèçèðîâàíî äëÿ òîãî ÷òîáû èìåòü äèàãíîñòè÷åñêèé laparoscopy èëè äèàãíîñòè÷åñêèé laparoscopy ñîâìåùåííûå ñ õèðóðãè÷åñêèìè ðåçåêöèåé èëè óäàëåíèåì óáûòîêîâ endometriosis. Âî âðåìÿ 36 íåäåëåé ïîñëåîïåðàöèîííîãî ïðîñëåæèâàíèÿ, 18% èç æåíùèí â äèàãíîñòè÷åñêîé ãðóïïå laparoscopy ñòàëî ñóïîðîñîé è 31% èç æåíùèí â äèàãíîñòè÷åñêîì laparoscopy ïëþñ ýêñöèçèÿ èëè óäàëåíèå ãðóïïû óáûòîêîâ endometriosis ñòàëî ñóïîðîñîé (ï<0.006). This well designed clinical trial suggests that surgical resection of endometriosis lesions can improve fertility in infertile women with endometriosis. However, pelvic surgery can cause pelvic adhesions, which can reduce fertility potential. Therefore, in the opinion of this author, infertile women should not have multiple operations to treat endometriosis lesions that are believed to be causing infertility. If the first adequate and complete operation is not followed by pregnancy during the next 12 months, then empirical induction of multi-follicular ovulation with clomiphene or gonadotropins in combination with intrauterine insemination is commonly recommended. Êëèíè÷åñêèå ïðîáû ïðåäëàãàþò ÷òî îáðàáîòêà íåïëîäîðîäíîñòè ñ èíäóêöèåé ìóëòè-follikul4rno1 îâóëÿöèè ñ clomiphene èëè gonadotropins in combination with âíóòðèóòðîáíîå îñåìåíåíèå ýôôåêòèâíà â îáðàáàòûâàÿ íåïëîäîðîäíîñòè ñâÿçàííîé ñ endometriosis. Fedele è êîëëåãàû õàîòèçèðîâàëè 40 æåíùèí ñ ýòàïîì iim èëè endometriosis è íåïëîäîðîäíîñòüþ ýòàïà II äî 3 öèêëà ëþäñêèõ menopausal âïðûñîê gonadotropin (lh è FSH-Pergonal, Repronex) ïëþñ âíóòðèóòðîáíîå îñåìåíåíèå (IUI) èëè ê íèêàêîé îáðàáîòêå. Âïðûñêè lh è FSH íàâîäÿò ìóëòè-follikul4rnuh îâóëÿöèþ. Òàðèô ñòåëüíîñòè â öèêë áûë 4.5% â ãðóïïå îáðàáîòêè íåò è 15% â ãðóïïå LH-FSH-IUI (ï<0.05). In a large randomized clinical trial, 932 women with infertility, many of whom had endometriosis, were randomized to receive intracervical sperm insemination (ICI) alone, intrauterine insemination (IUI), FSH (Gonal-F, Follistim) injections plus intracervical sperm insemination or FSH injections plus intrauterine insemination. Intracervical sperm insemination (ICI) was designed as a "control" that would resemble the effects of natural intercourse. Intrauterine insemination (IUI) is a commonly used fertility treatment where an ejaculated semen specimen is treated in the laboratory to concentrate the sperm in a small volume of buffer while removing all the semen. The concentrated sperm pellet is then delivered to the upper portion of the uterine cavity with a small catheter passed through the cervix. ICI and IUI are timed to occur just before ovulation with the use of urine LH detection kits. FSH injections are given to stimulate multi-follicular ovulation. After 4 treatment cycles, the pregnancy rate in each group was: FSH plus IUI-33%, FSH plus the control ICI treatment- 19%, IUI alone 18%, the control ICI treatment alone 10% (p<0.01). This study demonstrates that FSH plus IUI or FSH plus ICI, or IUI alone improves pregnancy rate over an intervention designed to simulate intercourse alone (ICI). A major complication associated with the FSH injections was twin and triplet pregnancy. The maternal and fetal risks associated with triplet pregnancy may diminish the clinical utility of FSH injections in this infertility setting. Compared to FSH, clomiphene (Serophene, Clomid) ovulation induction is associated with fewer twin and triplet pregnancies. Clomiphene plus IUI therapy may result in a better balance of benefits (pregnancy) and risks (triplet pregnancy) than FSH plus IUI therapy. Îáðàáîòêîé íåïëîäîðîäíîñòè, êîòîðàÿ èìååò áîëüøîé efficacy â æåíùèíàõ ñ endometriosis, áóäåò in vitro çåìëåóäîáðåíèåì è ïåðåõîäîì çàðîäûøà (IVF). IVF ñâÿçàíî ñ 30% â òàðèô ñòåëüíîñòè öèêëà â îáðàáîòêå íåïëîäîðîäíîñòè ïðè÷èíåííîé endometriosis.  ìíîãî öåíòðîâ, åñëè õèðóðãèÿ, ïîñëåäîâàííàÿ çà ÈÓÈ ñàìîñòîÿòåëüíî, ïîñëåäîâàëà çà ìóëòè-follikul4rno1 èíäóêöèåé îâóëÿöèè ïëþñ òåðïåòü íåóäà÷ó IUI äëÿ òîãî ÷òîáû ïðèâåñòè ê â ñòåëüíîñòè, òî IVF ïîðåêîìåíäîâàíî.  íåêîòîðûõ öåíòðàõ, IVF ïðåäëîæåíî íà "áûñòðîì êëèíè÷åñêîì ñëåäå" êàê ïåðâàÿ èíòåðâåíöèÿ â óñòàíîâêå endometriosis è íåïëîäîðîäíîñòè, ñïåöèàëüíî åñëè ìàëîïëîäîðîäíàÿ æåíùèíà áîëüøå ÷åì 37 ëåò âðåìåíè.  ïðàêòèêå àâòîðà, ìàëîïëîäîðîäíûå æåíùèíû < 32 years of age have the time to progress in a deliberate manner through all the standard treatment steps: surgery, IUI alone, clomiphene plus IUI, FSH injections plus IUI and finally IVF. For infertile women > 37 ëåò âðåìåíè, ïîêàçàíû, ÷òî èçáåãàåò áûñòðî ïðîãðåññèðîâàíèå ê IVF âîçìîæíîñòè ÷òî áóäóò èñòîùåíû âñå «çäîðîâûå» ôîëëèêóëû ïðåæäå ÷åì ñòåëüíîñòü áóäåò äîñòèãàíà.
Òàçîâàÿ Áîëü — Òðàäèöèîííûé Ïîäõîä:
Ìíîãî æåíùèí ñ endometriosis ïðåäñòàâëÿþò ñ òàçîâîé áîëüþ, âêëþ÷àÿ ñòðîãîå dysmenorrhea, dyspareunia, dyschezia è ïîíèæàþò ïîäáðþøíóþ áîëü îòíåñåííóþ ê menses. Ñòàíäàðòíûé ïîäõîä ê æåíùèíå ñ ñòðîãîé òàçîâîé áîëüþ, êîòîðàÿ íå èìåëà çíà÷èòåëüíî ñáðîñ áîëè ïîñëå òîãî êàê îíà îáðàáàòûâàíà ñ NSAIDs è óñòíî êîíòðàöåïòèâàìè, äîëæåí âûïîëíèòü laparoscopy äëÿ òîãî ÷òîáû îáóñëîâèòü ïðè÷èíó áîëè è óâèäåòü åñëè endometriosis ïðèñóòñòâóåò. Ïðåèìóùåñòâî óñòàíàâëèâàòü õèðóðãèþ â öåíòðàëüíîì ïîëîæåíèè â äèàãíîçå è îáðàáîòêå æåíùèí ñ òàçîâîé áîëüþ ÷òî îêîí÷àòåëüíûé äèàãíîç ìîæíî ÷àñòî îáóñëîâëèâàòü è åñëè endometriosis ïðîäåìîíñòðèðîâàíî, òî, õèðóðãè÷åñêàÿ ðåçåêöèÿ óáûòîêîâ ìîæåò ïðîèçâåñòè çíà÷èòåëüíî ñáðîñ áîëè äëÿ 12 ìåñÿöåâ èëè áîëüøå.  îäíîé õàîòèçèðîâàííîé controlled êëèíè÷åñêîé ïðîáå, õèðóðãè÷åñêàÿ ðåçåêöèÿ óáûòîêîâ endometriosis áûëà ïðîäåìîíñòðèðîâàíà ê ñáðîñó áîëè ïðîäóêöèè íà up to 12 ìåñÿöà ïîñëåîïåðàöèîííî.  ýòîì èçó÷åíèè, «àêòèâíî» õèðóðãè÷åñêàÿ ïðîöåäóðà ñîñòîÿëà äèàãíîñòè÷åñêîãî laparoscopy ñîâìåùåííîãî ñ óäàëåíèåì ëàçåðà óáûòîêîâ endometriosis ïëþñ óòðîáíîå óäàëåíèå íåðâà. Ìåòîäèêîé «ïðîâåðêè» õèðóðãè÷åñêîé áûë äèàãíîñòè÷åñêèé laparoscopy ïëþñ óñòðåìëåííîñòü òàçîâîé ïåðèòîíåàëüíîé æèäêîñòè. Âðà÷è îöåíèâàëè ðåàêöèþ ïàöèåíòîâ è ïàöèåíòîâ íå áûëè informed as to whether áûëà âûïîëíåíà äåÿòåëüíîñòü «àêòèâíî» èëè «óïðàâëåíèÿ».  ýòîì õàîòèçèðîâàííîì èçó÷åíèè, àêòèâíî õèðóðãè÷åñêàÿ ïðîöåäóðà ïðèâåëà ê â óëó÷øåíèè â áîëè â 63% èç æåíùèí è ìåòîäèêà ïðîâåðêè ïðèâåëà ê â óëó÷øåíèè â áîëè â 23% èç æåíùèí íà 6 ìåñÿöàõ ïðîñëåæèâàíèÿ (ï<0.01). This study suggests that surgical treatment of endometriosis can be effective in the treatment of pain. Íåäàâíèå êëèíè÷åñêèå ïðîáû ïðåäëàãàþò ÷òî ïîñëå õèðóðãè÷åñêîé îáðàáîòêè endometriosis, òåðàïèÿ èíêðåòè íà 6 ìåñÿöåâ ñ àãîíèñòîì GnRH çàäåðæèâàåò ðåöèäèâèðîâàíèå òàçîâîé áîëè ê 12 ìåñÿöà.  îäíîé êëèíè÷åñêîé ïðîáå, 109 æåíùèí ñ laparoscopically äîêàçàííûì endometriosis, êîòîðîå ïðîøëî laparoscopic îáðàáîòêó óáûòîêîâ endometriosis, áûëè õàîòèçèðîâàíû äëÿ òîãî ÷òîáû ïîëó÷èòü èëè àíàëîã ÃíÐÞ-agonista, nafarelin (Synarel) insufflation 200 ug íîñîâîå twice daily èëè insufflation ïëàöåáà íîñîâîå twice daily íà 6 ìåñÿöåâ ïîñëåîïåðàöèîííî. Ãëàâíîé ïåðåìåþþûì èñõîäà áûëî ìåäèàííîå âðåìÿ ïîñëå îáðàáîòêè ê íà÷àëó äðóãîé òåðàïèè, êîòîðàÿ îòðàæàåò ðåöèäèâèðîâàíèå ñòðîãîé òàçîâîé áîëè. Æåíùèíû áûëè îáðàáîòàíû ñ nafarelin ïîñëåîïåðàöèîííî èìåëè ìåäèàííîå âðåìÿ ê íà÷àëó äðóãîé òåðàïèè > 24 ìåñÿöà.  ãðóïïå îáðàáîòàííîé ñ ïëàöåáîì ìåäèàííîå âðåìÿ ê íà÷àëó äðóãîé òåðàïèè áûëî 12 ìåñÿöà (ï<0.001). This study suggests that the combination of surgery plus post-operative hormone therapy may be helpful in extending the time to recurrence of pelvic pain in women with endometriosis. The author offers all women with endometriosis post-operative hormone therapy with either a combination estrogen-progestin oral contraceptive or a GnRH agonist analogue. Òàçîâàÿ áîëü - ïîëüçà "êëèíè÷åñêîãî äèàãíîçà" Endometriosis:  íàñòîÿùåå âðåìÿ "çîëîòîéà ñòàíäàðò" äëÿ äèàãíîçà endometriosis áóäåò õèðóðãè÷åñêàÿ äîêóìåíòàöèÿ óáûòîêîâ endometriosis âèçóàëüíî îáíàðóæåíèåì. Ïðåèìóùåñòâà ýòîãî ïîäõîäà ÷òî î÷åíü ìàëîâåðîÿòíî ÷òî áóäåò ïðîïóùåíî èëè misdiagnosed ñåðüåçíîå ñîñòîÿíèå, such as îâàðèàëüíûé ðàê, è ÷òî îáðàáîòêà endometriosis ìîæåò îñóùåñòâèòü âî âðåìÿ õèðóðãè÷åñêîãî âèçóàëèçèðîâàíèÿ. Áóäóò íåñêîëüêî êëèíè÷åñêèå íåäîñòàòêè ê èñïîëüçîâàíèþ õèðóðãè÷åñêîãî âèçóàëèçèðîâàíèÿ óáûòîêîâ êàê "çîëîòîéà ñòàíäàðò" äëÿ äèàãíîçà endometriosis. Ýòè íåäîñòàòêè âêëþàþò: òðåáîâàíèå äëÿ õèðóðãèè è íàðêîòèçàöèè, âîçìîæíîñòè êîòîðóþ ìûñëüþ óáûòîêà, êîòîð áóäåò áûòü endometriosis èíñïåêöèîííûé îñìîòð íå ìîãëà äîêàçàòü äëÿ òîãî ÷òîáû áûòü endometriosis íà ãèñòîëîãè÷åñêîì àíàëèçå è âîçìîæíîñòè ÷òî íåêîòîðûå ãëóáîêèå óáûòîêè endometriosis ìîãëè áûòü òðóäíû äëÿ òîãî ÷òîáû âèçóàëèçèðîâàòü è ïîñëåäîâàòåëüí ïîñëå òîãî êàê îíè îáíàðóæåíû. Àëòåðíàòèâîé ê õèðóðãèè áóäåò ïîëüçà "êëèíè÷åñêîãî äèàãíîçà", îñíîâàííàÿ íà èñòîðèè, ôèçè÷åñêîå ðàññìîòðåíèå è íåèíâàçèâíûå ëàáîðàòîðíÿ èññëåäîâàíèå, äëÿ òîãî ÷òîáû ñäåëàòü äèàãíîç endometriosis. Íåäàâí îïóáëèêîâàííîå èçó÷åíèå ïîääåðæèâàåò ïðèíöèïèàëüíóþ ñõåìó äåëàòü "êëèíè÷åñêèé äèàãíîç" endometriosis â íåêîòîðûõ êëèíè÷åñêèõ ñèòóàöèÿõ, è èñïîëüçîâàíèÿ "ýïèðè÷åñêîé" îáðàáîòêè èíêðåòè äëÿ òàçîâîé áîëè ïðåäïîëàãàåìûå, ÷òî áûëî äîëæíî ê endometriosis. Íåäàâíåå èçó÷åíèå ñôîêóñèðîâàëî íà 100 æåíùèíàõ ñ õðîíè÷åñêîé òàçîâîé áîëüþ ñîîòâåñòâîâàëà 13 êðèòåðÿì ïî âêëþ÷åíèÿ: 1) óìåðÿåò ê ñòðîãîé õðîíè÷åñêîé òàçîâîé áîëè, 2) âðåìÿ îò 18 äî 45 ëåò, 3) ðåãóëÿðíî ìåíñòðóàëüíûå öèêëû, 4) íèêàêîé ðàíåå äèàãíîç endometriosis õèðóðãè÷åñêîé ïðîöåäóðîé, 5) íèêàêàÿ îáðàáîòêà èíêðåòè âíóòðè çà 3 ìåñÿöàìè, 6) íèêàêîå äîêàçàòåëüñòâî äëÿ ãëàâíûì îáðàçîì çàáîëåâàíèÿ ìî÷åâûäåëèòåëüíîãî òðàêòà èëè êèøå÷íèê êàê ïðè÷èíà áîëè, 7) íèêàêàÿ èñòîðèÿ ÷ðåçìåðíî ïîëüçû ñïèðòà, ñíàäîáèü òðàíêâèëèçàòîðà èëè illicit ñíàäîáèü, 8) íîðìàëüíûé òàçîâûé óëüòðàçâóê, 9) íîðìàëüíûé âïîëíå îòñ÷åò êðîâè, 10) íîðìàëüíûé urinalysis, 11) îòñóòñòâèå gonorrhea è chlamydia íà èñïûòàíèÿõ endocervical îáðàçöà, 12) îòðèöàòåëüíîå èñïûòàíèå ñòåëüíîñòè, è 13) îòêàç íîí-non-steroidal anti-inflammatory ëåêàðñòâ è îáðàáîòêè doxycylcine óëó÷øèòü ñèìïòîìû áîëè. Æåíùèíû áûëè õàîòèçèðîâàíû äëÿ òîãî ÷òîáû ïîëó÷èòü îáðàáîòêó ñ leuprolide äåïà (Lupron) 3.75 âïðûñêè ìàãíèÿ âíóòðèìûøå÷íûõ êàæäûå 4 íåäåëè íà 12 íåäåëè èëè ïîëó÷èòü âïðûñêó ïëàöåáà íà 12 íåäåëè. Áîëü áûëà èçìåðåíà ñ 4-point Biberoglu è ìàøòàáîì Behrman. Íà êîíöå îáðàáîòêè 12 íåäåëåé, âñå æåíùèíû ïðîøëè laparoscopy äëÿ òîãî ÷òîáû îïðåäåëèòü òî÷íîñòü "êëèíè÷åñêîãî äèàãíîçà" endometriosis. Íà êîíöå èçó÷åíèÿ, íà laparoscopy, áûëî îáóñëîâëåíî õèðóðãè÷åñêèì âèçóàëèçèðîâàíèåì óáûòîêîâ, êîòîðûì 87% èç æåíùèí â ãðóïïå ïëàöåáà è 78% æåíùèí â ãðóïïå leuprolide èìåëè endometriosis. Ýòî ïðåäëàãàåò ÷òî êðèòåðÿ ïî âêëþ÷åíèÿ 13 ïóíêòîâ ïåðå÷èñëåííàÿ âûøå îòíîñèòåëüíî ýôôåêòèâíà â îïðåäåëÿòü æåíùèí ñ õðîíè÷åñêîé òàçîâîé áîëüþ èìåþò endometriosis êàê ïðè÷èíà èõ áîëè (ïî êðàéíåé ìåðå â ýòîé íàñåëåííîñòè èçó÷åíèÿ). In addition, èçó÷åíèå ïîêàçàëî ÷òî 82% èç æåíùèí îáðàáîòàëî ñ ýïèðè÷åñêèì leuprolide èìåëî ñáðîñ áîëè áûòü ñðàâíåííûì äî 39% èç æåíùèí îáðàáîòàííûõ ñ ïëàöåáîì. Ýòîò ðåçóëüòàò ïîêàçûâàåò òî â æåíùèíàõ ñ êëèíè÷åñêèì äèàãíîçîì endometriosis, "ýïèðè÷åñêàÿ" îáðàáîòêà èíêðåòè ñ âïðûñêîé ìàãíèÿ äåïà 3.75 àöåòàòà leuprolide âíóòðèìûøå÷íîé êàæäûå 4 íåäåëè (Lupron) ñìîãèòå áûòü ýôôåêòèâí â ñáðàñûâàòü òàçîâóþ áîëü. Ýòî èçó÷åíèå, è äðóãèå, ïîääåðæèâàþò ïðèíöèïèàëüíóþ ñõåìó äåëàòü êëèíè÷åñêèé äèàãíîç endometriosis îñíîâàííûé íà èñòîðèè, ôèçè÷åñêèõ çàêëþ÷åíèÿõ è ëèìèòèðîâàííîì ïî ïðîâåðêå ëàáîðàòîðèè. Æåíùèí êëèíè÷åñêè äèàãíîñòèðîâàííûå ñ endometriosis ìîæíî ïîñëå ýòîãî ïðåäëîæèòü îáðàáîòêó ñ àíàëîãîì GnRH, danazol èëè ïðîãåñòèíîì äëÿ èõ òàçîâîé áîëè. Íåäàâíèé àìåðèêàíñêèé êîëëåæ òåõíè÷åñêèé áþëëåòåíü obstetricians è gynecologists, "ìåäèöèíñêîå óïðàâëåíèå Endometriosis", îáñóäèë ýòó ýâîëþöèîíèðóÿ êëèíè÷åñêóþ ïàðàäèãìó è çàêëþ÷èë ÷òî êëèíè÷åñêèé äèàãíîç endometriosis è ýïèðè÷åñêîé îáðàáîòêè èíêðåòè ìîæåò áûòü efficacious. Hysterectomy è äâóõñòîðîííèé oophorectomy: Áûëè ñîîáùåíû, ÷òî îáåñïå÷èâàþò hysterectomy è äâóõñòîðîííèé oophorectomy (TAH_BSO) äîëãîñðî÷íûé ñáðîñ áîëè â ïðèáëèçèòåëüíî 85% èç æåíùèí ñ endometriosis. Îáðàáîòêà TAH-BSO òîëüêî èìåþùÿÿñÿ ê æåíùèíàì îïðåäåëåííî çàâåðøàëè èõ ñåìüþ. Ïîñëå TAH-BSO, òåðàïèÿ çàìåíû èíêðåòè ñ ñòàíäàðòíûìè ðåæèìàìè ìîæåò îáðàáîòàòü âàçîìîòîðíûå ñèìïòîìû áåç óâåëè÷èâàòü ðèñê ðåöèäèâèðîâàíèÿ endometriosis è òàçîâîé áîëè. Øèðîêîìàñøòàáíûå ïðîáû ïðîñëåæèâàíèÿ ïîêàçûâàþò ÷òî æåíùèíû ñ endometriosis è ñòðîãîé òàçîâîé áîëüþ áûëè îáðàáîòàíû ñ TAH-BSO èìåþò äîëãîñðî÷íîå óëó÷øåíèå â èõ ñèìïòîìàõ áîëè è óäîâëåòâîðÿþòñÿ ñ èõ âûáîðîì îáðàáîòêè. Ìåäèöèíñêÿ ëå÷åíèå òàçîâîé áîëè ïðè÷èíåííûé Åíäîìåòðèîñèñ: Æåíùèí ñ endometriosis è òàçîâîé áîëüþ ìîæíî óñïåøíî îáðàáîòàòü ñ òåðàïèåé èíêðåòè. Ïðàêòèêà àâòîðà äîëæíà íà÷àòü ñ îáðàáîòêàìè èíêðåòè ñ íåìíîãèìè ïîáî÷íûìè ýôôåêòàìè (íîí-non-steroidal anti-inflammatory âåùåñòâàìè èñïîëüçóåìûìè íà ïî÷òè maximal äîçàõ, óñòíî êîíòðàöåïòèâàõ èñïîëüçóåìûõ â öèêëîâîì èëè íåïðåðûâíîì îáðàçå) è ïîñëå ýòîãî ðàçâèòü ïîñëåäîâàòåëüí äëÿ èñïîëüçîâàíèÿ áîëåå ìîùíûõ îáðàáîòîê èíêðåòè êîòîðûå ñâÿçàíû ñ çíà÷èòåëüíî ïîáî÷íûìè ýôôåêòàìè (àíàëîãàìè GnRH such as nafarelin è leuprolide, danazol). Ýòî ïðîãðåññèðîâàíèå êîíñïåêòèðîâàíî â òàáëèöå 2. Êàæåòñÿ, ÷òî áóäåò êîíòðàöåïòèâ ñòàíäàðòíîãî ýñòðîãåí-progestina êîìáèíàöèè óñòíî ýôôåêòèâí â îáðàáîòêå òàçîâîé áîëè ïðè÷èíåííîé endometriosis. Ñòàíäàðòíàÿ óñòíî ïðîòèâîçà÷àòî÷íàÿ ïèëþëüêà ñîäåðæèò ïðîãåñòèí â êàæäîé ïèëþëüêå. Ïðîãåñòèí ïðåãðàæäàåò ðîñò â ìíîãî óáûòîêîâ endometriosis, â ÷àñòè, ïóòåì ïðåãðàæäàòü ðîñò ïîâûøàÿ ñâîéñòâà ýñòðîãåíà. Àëòåðíàòèâà ê ñòàíäàðòíîìó ïëàí-ãðàôèêó (21 ïèëþëüêå èíêðåòè, ïîñëåäîâàííîé çà ê 7 äíåé ñ ïèëþëüêè) äëÿ administering êîíòðàöåïòèâû ýñòðîãåí-progestina êîìáèíàöèè óñòíî äîëæíà ïðåäïèñàòü 63 àêòèâíî ïèëþëüêè èíêðåòè â ðÿäêå (3 ïàêåòàõ 21 àêòèâíî ïèëþëüêè) ïîñëåäîâàííîì çà ê 7 äíåé ñ ïèëþëüêè, ïîñëåäîâàííîé çà 63 àêòèâíî ïèëþëüêàìè â ðÿäêå. Ýòîò ïîäõîä áûë îïèñàí àâòîðîì êàê "minia4-pseudopregnancy" ïîòîìó ÷òî îí ÷àñòî ïðèâîäèò ê â menses êàæäûå 10 íåäåëåé rather than êàæäûõ 4 íåäåëÿõ. Äàæå äëèòåëüíûéà öèêë ìîæåò áûòü ïðåäïèñàí ïóòåì ðåêîìåíäîâàòü ïîëüçó 105 (5 ïàêåòîâ 21 àêòèâíî ïèëþëüêè) â ðÿäêå, ïîñëåäîâàííîì çà ê 7 äíåé ñ ëåêàðñòâà, ïîñëåäîâàííîãî çà 105 àêòèâíî ïèëþëüêàìè â ðÿäêå.  îäíîì èçó÷åíèè, æåíùèíû êîòîðûå áûëè ïîçâîëåíû ðàñøèðèòü ÷èñëî ïîñëåäîâàòåëüíûõ àêòèâíî ïèëþëåê è èçáåæàòü ïèëþëüêó ñâîáîäíî íåäåëÿ ñîîáùèëè âûñîêèé ñòåïåíü ñîîòâåòñòâèÿ ñ âûäâèíóòûì ðåæèìîì ïèëþëüêè. Ãëàâíûé íåäîñòàòîê ê ïîëüçå "äëèòåëüíûéà öèêë" ÷òî ìíîãî æåíùèí íà÷èíàþò "êðîâîòå÷åíèå ïðîðûâà" è èìåþò ìàëîå êîëè÷åñòâà óòðîáíîãî êðîâîòå÷åíèÿ, ÷àñòî ñîîáùàåìûå, ÷òî áûëè êîðè÷íåâû â öâåòå, ìíîãî äíåé â íåäåëþ. Ïðîëîìîì ÷åðåç êðîâîòå÷åíèå áóäåò æåíùèíû ãëàâíàÿà ïðè÷èíà èñïîëüçóÿ "miniuh-pseudopregnancy" ïðåðûâàåò ëåêàðñòâî. Åñëè óñòíî êîíòðàöåïòèâû íå ýôôåêòèâíû ïîñëå ýòîãî, òî ïàöèåíòà ìîæíî îáðàáîòàòü ñ nafarelin (Synarel) 200 ug twice daily íîñîâûì äåïîì àöåòàòà insufflation èëè leuprolide (Lupron), âïðûñêîé ìàãíèÿ 3.75 âíóòðèìûøå÷íîé êàæäûå 4 íåäåëè. Ñòàíäàðòíûì êóðñîì îáðàáîòêè àãîíèñòà GnRH áóäåò 24 íåäåëè, íî ðåæèìû îáðàáîòêè êàê ñêîðî êàê áûëè ïîêàçàíû, ÷òî áóäóò 12 íåäåëè ýôôåêòèâíû. Àíàëîãè àãîíèñòà GnRH, nafarelin è leuprolide, ïåðâîíà÷àëüíî ñòèìóëèðóþò pituitary îòïóñê lh è FSH, íî ñ õðîíè÷åñêîé ïîëüçîé, îíè ïàðàäîêñàëüíî âíèç-reguliruet ñåêðåòèðîâàíèå lh è FSH, resulting in cessation îâàðèàëüíîãî ôîëëèêóëÿðíîãî ðîñòà è ïîäàâëåíèå îâàðèàëüíîé ïðîäóêöèè ýñòðîãåíà è ïðîãåñòèíà. Îòñóòñòâèå îâàðèàëüíîé ïðîäóêöèè ýñòðîãåíà è ïðîãåñòèíà, ïðèâîäèò ê â amenorrhea è hypoestrogenic ïîáî÷íûõ ýôôåêòàõ such as ãîðÿ÷èå âñïûøêè è óâåëè÷åííûé òàðèô ðåçîðáöèè êîñòî÷êè. Hypoestrogenism íàâåäåííîå àãîíèñòàìè GnRH ñâÿçàíî ñ ñáðîñîì òàçîâîé áîëè â ïðèáëèçèòåëüíî 85% èç æåíùèí ñ endometriosis. Ýòî ñèëüíîå ïîëîæèòåëüíîå âîçäåéñòâèå áûòü ñáàëàíñèðîâàííûì ïðîòèâ ïîáî÷íûõ ýôôåêòîâ ãîðÿ÷èõ âñïûøåê è ïîòåðè êîñòî÷êè. Äëÿ íåêîòîðûõ æåíùèí, ñáðîñ áîëè ïîýòîìó èìïðåññèâíî è ïîáî÷íî ýôôåêòû áóäüòå íàñòîëüêî ìèíèìàëüí ÷òî îíè õîòÿò îñòàòüñÿ íà îáðàáîòêå íà áîëåå äëèíîé ÷åì 6 ìåñÿöåâ. Ýòî áåçîïàñíî, åñëè êîíòðîëèðóþò ïàöèåíòà áûòü îñòîðîæíûì äëÿ ïîòåðè êîñòî÷êè. ñòåðîèä Íèçê-dozy "äîáàâëÿåò íàçàä" ìîæíî äîáàâèòü, ÷òî ê îáðàáîòêå àãîíèñòà GnRH óìåíüøèë òàðèô ïîòåðè êîñòî÷êè è îáðàáîòàë ãîðÿ÷èå âñïûøêè. Dobav6te-nazad ðåæèìû, êîòîðûå áûëè ïðîäåìîíñòðèðîâàíû, äëÿ òîãî ÷òîáû áûòü ýôôåêòèâí ïåðå÷èñëèòå â òàáëèöå 3. Ïîñëå discontinuation îáðàáîòêè, òàçîâàÿ áîëü êëîíèò ðåöèäèâèðîâàòü â áîëüøèíñòâ æåíùèíàõ íàä ñëåäóþùèìè 12 ìåñÿöàìè. Danazol (Danocrine), óñòíî àêòèâíî ïðîèçâîäíûé òåñòîñòåðîíà, êàê ýôôåêòèâíî êàê nafarelin è leuprolide â îáðàáîòêå òàçîâîé áîëè ïðè÷èíåííîé endometriosis. Danazol òèïè÷íî ïðåäïèñàíî íà äîçàõ ìàãíèÿ 200 twice daily íà up to 6 ìåñÿöåâ. Åñëè ýòà äîçà íå ýôôåêòèâíà â ñáðàñûâàòü òàçîâóþ áîëü, òî äîçó ìîæíî óâåëè÷èâàòü ê ìàãíèþ 200 3 èëè 4 âðåìåíè åæåäíåâíî. Danazol no longer øèðîêî íå èñïîëüçîâàíî äëÿ îáðàáîòêè endometriosis ïîòîìó ÷òî îíî ñâÿçàíî ñ çíà÷èòåëüíî óâåëè÷åíèåì âåñà (average-4 êèëîãðàììîì), óãëóáëÿòü ãîëîñà, ãèðñóòèçìà è musculoskeletal áîëè.  íàñòîÿùåå âðåìÿ ïîëüçà danazol êëîíèò áûòü êàê "ïîñëåäíåå ñðåäñòâî" ïîñëå NSAIDs, óñòíî êîíòðàöåïòèâîâ è àíàëîãè àãîíèñòà GnRH íå ñóìåëè ïîäõîäÿù îáðàáîòàòü òàçîâóþ áîëü ïðè÷èíåííóþ endometriosis.
Ïðàêòèêà Áîëè Ìóëòè-Speqial6nosti:
Ãëàâíàÿ âîçìîæíîñòü â îáðàáîòêå áîëè äîëæíà ýôôåêòèâíî èíòåãðèðîâàòü ïàðàäèãìû ïñû÷þîñî÷èàë-ðàçóì-ìîçã-tela. Psychosocial ïàðàäèãìà ïîä÷åðêèâàåò âàæíîñòü ñîöèàëüíûõ ñîñòîÿíèÿ è îïûòîâ â ñåìüå è îáùåñòâî íà èñõîäàõ çäîðîâüÿ. Ïàðàäèãìà ðàçóìà ïîä÷åðêèâàåò âàæíîñòü ïñèõîëîãè÷åñêèé ôàêòîð íà çäîðîâüå. Ïàðàäèãìà ìîçãà ôîêóñèðóåò íà íåðâíûõ ãåíàõ è íåéðîõèìèè â ýòèîëîãèè áîëè. Ïàðàäèãìà òåëà ôîêóñèðóåò íà diseased îðãàíàõ âûçûâàþò ñòèìóë áîëè. Áóäåò ample äîêàçàòåëüñòâî â æåíùèíàõ ñ endometriosis è òàçîâîé áîëüþ, ôàêòîðàìè such as íàæàòèå, somatization, çà èñòîðèåé ðîëåé ñåêñóàëüíîé èëè ïñèõîëîãè÷åñêîé èãðû çëîóïîòðåáëåíèåì âàæíûõ â ìîäóëÿöèè âîñïðèíÿòèÿ ïàöèåíòà åå áîëè. Äëÿ ïàöèåíòîâ ñ òàçîâîé áîëüþ íå èìåëè çíà÷èòåëüíî ñáðîñ îò ãîðìîíàëüíîé èëè õèðóðãè÷åñêîé îáðàáîòêè, multispecialty ïðàêòèêà áîëè ìîæåò äîêàçàòü áûòü ýôôåêòèâíà.
Áóäóò íåìíîãèå õàîòèçèðîâàííûå èçó÷åíèÿ efficacy ïñèõîëîãè÷åñêèõ èëè psychosocial interventions â îáðàáîòêå òàçîâîé áîëè.  îäíîé êëèíè÷åñêîé ïðîáå, ýôôåêòèâíîñòü ñôîêóñèðîâàííîãî îðãàíè÷åñêîãî (õèðóðãè÷åñêîãî) ïîäõîäà ê òàçîâîé áîëè áûëà ñðàâíåíà ê multidisciplinary ïîäõîäó ê òàçîâîé áîëè êîòîðàÿ âêëþ÷èëà õèðóðãè÷åñêèå, ïñèõîëîãè÷åñêèå, äèåòè÷åñêèå è ñîöèàëüíûå interventions. Èññëåäîâàòåëè ñîîáùèëè ÷òî multidisciplinary ïîäõîä ê òàçîâîé áîëè ïðèâåë ê â áîëüøîì, äîëãîñðî÷íîì óëó÷øåíèè â ñîáñòâåíí-soob5ennyx ñ÷åòàõ áîëè ÷åì ïîäõîä êîòîðûé ñôîêóñèðîâàë íà îáðàáàòûâàÿ îðãàíè÷åñêîì çàáîëåâàíèè ñ õèðóðãèåé. Áîëüøèíñòâ áîëüøèå ìåäèöèíñêèå öåíòðû èìåþò îðãàíèçîâàííûé öåíòð îáðàáîòêè áîëè ìîæåò íà÷àòü multidisciplinary ïëàí îáðàáîòêè äëÿ ïàöèåíòà ñ õðîíè÷åñêîé òàçîâîé áîëüþ íå ñóìåëà îòâåòèòü ê õèðóðãè÷åñêîå âìåøàòåëüñòâî è îáðàáîòêå èíêðåòè.
Áûñòðî äèàãíîç êðèòè÷åñêè ê ïðàâèëüíîé îáðàáîòêå çàáîëåâàíèÿ. 2 íåçàâèñèìî èçó÷åíèÿ ñîîáùèëè ÷òî ñðåäíÿÿ ïðîäîëæèòåëüíîñòü ìåæäó onset ñèìïòîìîâ endometriosis (òàçîâîé áîëè) è îêîí÷àòåëüíûé äèàãíîç íàõîäèëñÿ íàä 6 ëåòàìè. Çàäåðæèâàåò ìåæäó onset ñèìïòîìîâ è îêîí÷àòåëüíûõ ðåçóëüòàòîâ äèàãíîçà â çíà÷èòåëüíî ôðóñòðàöèè êàê äëÿ ïàöèåíòîâ òàê è äëÿ clinicians. Çàäåðæèâàåò â äèàãíîçå endometriosis ñìîãèòå áûòü óìåíüøåíî åñëè clinicians àêòèâíî ðàññìàòðèâàþò äèàãíîç â âñåõ æåíùèíàõ ñ òàçîâûìè áîëüþ èëè íåïëîäîðîäíîñòüþ.
Òàáëèöà 1: Ïîñëåäîâàòåëüíûé ïîäõîä ê îáðàáîòêè ê æåíùèíå ñ íåïëîäîðîäíîñòüþ è endometriosis.
Step1: Õèðóðãè÷åñêèå äèàãíîç è îáðàáîòêà. Ïðîñëåæèâàíèå íà 12 ìåñÿöà äëÿ òîãî ÷òîáû óâèäåòü åñëè ñòåëüíîñòü ïðîèñõîäèò.
Step2: Âíóòðèóòðîáíîå îñåìåíåíèå.
Ðàçäåë 3: Èíäóêöèÿ Clomiphene ìóëòè-follikul4rno1 îâóëÿöèè ïëþñ âíóòðèóòðîáíîå îñåìåíåíèå.
Ðàçäåë 4: Âïðûñêè FSH äëÿ èíäóêöèè ìóëòè-follikul4rno1 îâóëÿöèè ïëþñ âíóòðèóòðîáíîå îñåìåíåíèå.
Ðàçäåë 5: In vitro çåìëåóäîáðåíèå è ïåðåõîä çàðîäûøà (IVF)
Òàáëèöà: Ãîðìîíàëüíûå îáðàáîòêè äëÿ òàçîâîé áîëè ïðè÷èíåííîé endometriosis. Interventions ðàçäåëà 1.2 è 3 ñâÿçàíû ñ áîëåå ìåíåå ñòðîãèìè ïîáî÷íûìè ýôôåêòàìè ÷åì îáðàáîòêè ðàçäåëà 4 è 5.
Ðàçäåë 1: Íîí-non-steroidal anti-inflammatory âåùåñòâà íà maximal äîçàõ.
Ðàçäåë 2: Óñòíî êîíòðàöåïòèâû èñïîëüçóåìûå â öèêëîâîì îáðàçå.
Ðàçäåë 3: Óñòíî êîíòðàöåïòèâû èñïîëüçóåìûå â «äëèíí-qiklax».
Step 4: Ðàçäåë 4: Îáðàáîòêà àãîíèñòà GnRH ñåòíîàÿ-àíàëîãîâ: nafarelin (Synarel- 200ug íîñîâûì ïðåäëîæåííûì öåíó insufflation) èëè leuprolide (äåïî Lupron, 3.75 wks ìàãíèÿ IM ö 4)
Ðàçäåë 5: Danazol (çàÿâêà Danocrine-200mg po. èëè tid èëè qid, åæåäíåâíûå)
Òàáëèöà 3: Steroidal dobav6te-nazad ðåæèìû ìîãóò óìåíüøèòü òàðèô ïîòåðè êîñòî÷êè è ãîðÿ÷èõ âñïûøåê ñâÿçàííûõ ñ îáðàáîòêîé àãîíèñòà GnRH (nafarelin èëè leuprolide).
| Dobav6te-Nazad Ëåêàðñòâî | Äîçà |
| Àöåòàò Norethindrone (Aygestin) | 5 ìàãíèé po åæåäíåâíûé |
| 17beta-estradiol, transdermal çàïëàòà ïëþñ Àöåòàò Medroxyprogesterone (Provera) | çàïëàòà 25 ug ìàãíèé 5 åæåäíåâíûé |
| 17beta-estradiol, micronized (Estrace) Àöåòàò Norethindrone (Aygestin) | 22 ìàãíèé po åæåäíåâíûég 1 ìàãíèé po åæåäíåâíûé |
| Ïðîñïðÿãàííûé Equine Ýñòðîãåí (Premarin) Àöåòàò Medroxyprogesterone (Provera)TD> | 0.625 ìàãíèÿ po åæåäíåâíîãî 5 ìàãíèé po åæåäíåâíûé |
| Ïðîñïðÿãàííûé Equine Ýñòðîãåí (Premarin) Àöåòàò Medroxyprogesterone (Provera)TD> | 0.3 ìàãíèÿ po åæåäíåâíîãî 5 ìàãíèé po åæåäíåâíûé |
Ïðèìå÷àíèå Ðåäàêòîðà:
Ïðèçíàòåëüíîñòü âûðàæåíà ê Äð. robert L Áàðáèåðè äëÿ åãî priceless ïîîùðåíèÿ è ïîääåðæêè. Åãî ïèîíåðñêàÿ ðàáîòà â âîñïðîèçâîäñòâåííîì çäîðîâüå ïîìîãàëà ìèëëèîíàì æåíùèí âñåìèðíî. Ìû òàêæå thankful ê Æóëüíè÷àòü-Terapii äëÿ äàâàòü íàì ïîçâîëåíèå íàïå÷àòàòü åãî. ×èòàòåëè îáîäðåíû ïîñåòèòü web site who íà âîñïðîèçâîäñòâåííîì çäîðîâüå:
www.who.int/reprodutive-health